Web Content Viewer


Nursing Home and Facilities Forms Main Page


The forms on this page allow an individual or corporation to, among other things, apply for a nursing home license, renew an existing license, request a RN waiver, and apply for certification for participation in the federal Medicare/Medicaid programs.


Licensure Forms

 Long Term Care - Initial License Application Packet  August 2015
 Long Term Care - Initial Application  September 2015
 Nursing Home - Initial Application Instructions  August 2015
 Nursing Home - Notice of Readiness  September 2015
 Long Term Care License Renewal Form  January 2015
 Long Term Care Change of Operator License Application  August 2011
 Fire Safety - Self Inspection Form  September 2011
 Registered/Licensed Nurse Staffing Waiver Application  November 2014


Medicare Application Process and Forms

The Ohio Department of Health (ODH) is the state survey and certification agency for the Centers for Medicare and Medicaid Services (CMS).  To assist CMS in determining whether institutions and agencies can participate in Medicare, ODH obtains and reviews documents needed for application and certifies whether providers of services meet the Medicare Conditions of Participation.  Your institution cannot claim provider reimbursement for services furnished prior to approval. 

Your facility must be licensed as a nursing home with the State of Ohio prior to obtaining Medicare Certification.


  • CMS-671 Long Term Care Facility Application for Medicare and Medicaid

  • ​CMS-1561 Health Insurance Benefit Agreement

  • Civil Rights Verification or Package including policies and procedures

  • HHS 690 Assurance of Compliance forms

  • Transfer Agreement

            Ohio Department of Health
            OHAL/BRO - Certification Unit
            246 North High Street, 3rd Floor
            Columbus, OH 43215

CMS-671 Long Term Care Facility Application for Medicare and Medicaid

Click on the “CMS-671” link above, complete form and submit one (1) signed original.  The person completing the form must print name and sign the form and record the date and time the form was completed on the bottom of page 2. 


CMS-1561 Health Insurance Benefit Agreement

Click on the “CMS-1561” link above, complete form and submit two (2) signed originals. 

Enter the name of the business entity, followed by the D/B/A (trade name).  Ordinarily, the business entity name is the same as the business name used on all official IRS correspondence concerning payroll withholding taxes, such as the W-3 or 941 forms. 

For example, the ABC Corporation, owner of the Community General Hospital, would enter on the agreement, "ABC Corporation D/B/A Community General Hospital."  A partnership of several persons might complete the agreement to read:  "Robert Johnson, Louis Miller and Paul Allen, partners, D/B/A Easy Care Home Health Services."  A sole proprietorship would complete the agreement to read:   "John Smith D/B/A Mercy Hospital."  The person signing the Health Insurance Agreement must be someone who has the authorization of the owners of the enterprise to enter into this agreement.


Civil Rights Package

Medicare Part A providers will be required to sign an attestation of their compliance with all applicable civil rights laws enforced by OCR (including Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, and Section 1557 of the Affordable Care Act). This attestation is referred to as an Assurance of Compliance and it can be found on the HHS website (Form HHS-690).   

New applicants for Medicare funding and current providers undergoing a CHOW will be responsible for submitting this attestation electronically to the OCR via OCR’s online Assurance of Compliance portal at https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf. The provider will receive electronic verification from OCR of successful submission of the attestation.

Providers forwarding notification of a CHOW must submit evidence of successful electronic submission of the above attestation (Form HHS-690) through the OCR portal before an initial survey may be conducted or the CHOW may be processed.

If the OCR receives complaints of discrimination subsequent to an initial certification or a CHOW, it may utilize any of its enforcement tools, including compliance reviews, technical assistance, new policy guidance and educational opportunities to assist an entity in coming into compliance with relevant civil rights laws. In the event the provider/supplier does not regain compliance, the OCR will notify the applicable CMS RO and termination of the provider agreement will be initiated.

Please submit the screen shot that confirms the HHS 690 attestation submission back to the Ohio Department of Health along with the civil rights application (policy/procedures).


Transfer Agreement

Submit a copy of a signed written transfer agreement entered into between the facility and a hospital approved for participation under the Medicare and Medicaid programs.  See 42 CFR 483.75(n) for specific requirements of the written transfer agreement.



CMS-855 Provider/Supplier Enrollment Application

Approval by the fiscal intermediary is required before the state agency can schedule an onsite survey.  To obtain this form, click on the “CMS-855” link above or call the fiscal intermediary at (866) 590-6703 and submit the completed form as instructed.   It may take up to six (6) months for ODH to receive approval by the Fiscal Intermediary. 



Office of Civil Rights HIV/AIDS Information Sheet

Click on the link above to obtain documentation referencing Civil Rights and AIDS or AIDS-related conditions.


Conditions of Participation

Click on the link above to obtain the Conditions of Participation that are set forth in 42 CFR Part 483.



ODH will conduct a Medicare certification survey after receipt of a complete Medicare Application Packet and the fiscal intermediary approval of the CMS Form 855, and notification that the facility is ready for survey.  The notice of readiness must be submitted on facility letterhead, signed by an authorized representative of the facility and state the date the facility will be ready for a certification survey. 

Following the survey, ODH will submit the application packet to CMS and make a recommendation as to whether or not the facility should participate in the Medicare program. 



CMS takes approximately eight (8) weeks to determination whether the facility meets the requirements to participate in the Medicare program. CMS requires that the application documents be signed no more than six (6) months prior to CMS’ review.  If the process takes more than six (6) months, CMS may require the facility to submit updated forms. 

Once the process is complete, CMS will notify the facility of its determination.  If CMS approves the facility for participation in the Medicare program, CMS will send an approval letter containing the facility’s Medicare number and effective date, as well as a signed copy of the Health Insurance Benefit Agreement to the facility.

If CMS denies approval to participate in the Medicare program, CMS will send the facility notification of denial and provide the reasons for the denial, and provide information about the facility’s rights to appeal the decision.



If you have questions about the application process, you may contact the OHAL/BRO -  Certification Unit at liccert@odh.ohio.gov or call (614) 644-8118.
If you have questions about the status of your CMS-855 form, contact the fiscal intermediary at (866) 590-6703.